Non-Member 2019 Shaarai Family Retreat

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Congregation Shaarai Shomayim Family Retreat

April 5-7, 2019

Join Shaarai Shomayim friends, old and new, at beautiful Capital Retreat Center!

Cost to friends from the Jewish Community:

$310 per adult (13 and under)
$240 per youth (ages 5-12)
$50 per child under 5 years of age
$400 single room for those who prefer not to have a roommate

Note: Non-refundable deposit of $100 per family or $50 per single is required at time of on-line registration. The balance is due by February 15, 2019.

REGISTRATION INFORMATION:

Complete the information below as it pertains to each member of your family who will be attending the 2019 Family Retreat.

* STREET ADDRESS

* CITY

* ZIP CODE

# of Adults/Teens Attending (13 and older)

$310 per adult

# of Children Attending (ages 5 - 12)

$240 per youth

# of Children Attending (under age 5)

$50 per child

* SINGLE ROOM REGISTRATION

$400 single room for those who prefer not to have a roommate

ADULT #1:

* FIRST NAME

* LAST NAME

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

ADULT #2:

FIRST NAME

LAST NAME

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

CHILD/TEEN #1:

FIRST NAME

LAST NAME

DATE OF BIRTH

(mm/dd/yyyy)

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

CHILD/TEEN #2:

FIRST NAME

LAST NAME

DATE OF BIRTH

(mm/dd/yyyy)

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

CHILD/TEEN #3:

FIRST NAME

LAST NAME

DATE OF BIRTH

(mm/dd/yyyy)

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

CHILD/TEEN #4:

FIRST NAME

LAST NAME

DATE OF BIRTH

(mm/dd/yyyy)

PHYSICAL CONSIDERATIONS

Please list any physical accommodations, medical conditions, etc.

FOOD OR ALLERGY CONSIDERATIONS

Please list any allergies and/or dietary needs

IN THE CASE OF AN EMERGENCY:

Please provide a contact in the case of an emergency.

* EMERGENCY CONTACT #1:

Name, Relationship, Phone Number

REQUEST TO USE PHOTOGRAPH/VIDEO:

Photos/videos of participants are often used in the Temple's public relations programs. Choose No if you DO NOT want your photo to be represented in newspapers, TV, the Temple's/web communications. Please note that this does include the posting of pictures on all the Temple's social media including the website, Facebook, Instagram and Twitter.

CHECK BOX IF DECLINING USE OF PHOTOS/VIDEOS:

NO; Shaarai Shomayim may not use the photos/videos

TOTAL DUE:

Thank you for registering for the Shaarai Shomayim Congregational Retreat!

Tue, April 23 2024 15 Nisan 5784

Non-Member 2019 Shaarai Family Retreat

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